Provider Demographics
NPI:1649371600
Name:COLLETTI MD PC
Entity type:Organization
Organization Name:COLLETTI MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANNI
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOODRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-322-1880
Mailing Address - Street 1:1001 JONES ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-5512
Mailing Address - Country:US
Mailing Address - Phone:775-322-1880
Mailing Address - Fax:775-322-1897
Practice Address - Street 1:1001 JONES ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5512
Practice Address - Country:US
Practice Address - Phone:775-322-1880
Practice Address - Fax:775-322-1897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016499Medicaid